One Medical Group Scholarship →

One Medical Group—a forward thinking primary care practice—is offering a $10,000 scholarship for 3rd year med students interested in primary care.

If you haven’t heard of One Medical Group, you should really check them out (and not just for the scholarship opportunity). They are among a handful of practices trying to reshape the face of primary care. The NY Times had an excellent article about them a couple years ago.

The application opens Jan 10 and closes Mar 14. This is a great opportunity for some ‘free money’!

"We Need to Talk About TED" | Benjamin Bratton →

Excellent critique of the increasingly popular ‘TED talk’ format. He writes [emphasis mine]:

Let me tell you a story. I was at a presentation that a friend, an astrophysicist, gave to a potential donor. I thought the presentation was lucid and compelling…After the talk the sponsor said to him, “you know what, I’m gonna pass because I just don’t feel inspired… you should be more like Malcolm Gladwell.”

At this point I kind of lost it. Can you imagine?

Think about it: an actual scientist who produces actual knowledge should be more like a journalist who recycles fake insights! This is beyond popularization. This is taking something with value and substance and coring it out so that it can be swallowed without chewing.

The whole post really is great and worth the read. I have had similar thoughts and wrote about one deficiency of the format after I attended TEMED in 2012. I have reproduced that post below.

The missing element of TEDMED - critical discussion (Apr 2012)

TEDMED is a conference that bills itself as, “… a safe place where people with very different ideas can come together to talk, to learn and to celebrate the amazing world we live in.” Speakers and performers—all leading experts in their respective fields—come together to share their ideas about the future of medicine and technology. Presentations are only limited by the speaker’s imagination and the 18 minute time limit. TEDMED’s openness to imaginative ways of thinking about medicine, health care, biomedical research, and well-being produces 4 days of mind-bending talks and performances.

Despite TEDMED’s decidedly forward-thinking subject matter and format, one critical element is missing from the formal structure of the conference–critical discussion of presentations. Almost every single “traditional” medical conference features talks followed by a brief period for public discussion with the presenter about their ideas. TEDMED is devoid of such public critical discussion. Instead, discussions are relegated to the attendees analyzing presentations amongst themselves during breaks in the Social Hub (TEDMED’s sponsor venue) or short exchanges on Twitter or blog posts weeks after the event when the videos are posted online.

Jay Walker—TEDMED’s chairman and emcee for the event—provides some faux analysis after each speaker in the form of a brief summary and a few crowd-sourced questions. However, this serves more to simply reinforce the speaker’s thesis and stroke their ego than critically analyze what he or she said.

The lack of critical analysis consequently allows some speakers to freely conflate marginally related ideas and invoke anecdotal evidence in support of their hyperbolic assertions. It also misses a tremendous opportunity. TEDMED is much more than the small lineup of speakers; its attendees (TEDMED calls them “delegates”) are also innovators and broad-thinkers at the cutting edge of medicine and health care. Why not allow them to engage with the speakers in a public forum for all to hear? While at TEDMED this year, I had some of the most engaging discussions with other attendees and a hundred such discussions occurred at each break. It is a shame a piece of these discussions are not captured for the public.

As often as I am able, I like to suggest a solution whenever I see a problem. I think the solution here is to add a component to the TEDMED Connect app whereby attendees can verbally ask questions and engage with the speakers in a brief discussion session after each talk. During the talk, attendees in the room can jump onto the TEDMED Connect app and touch a button indicating they would like to ask a question at the end of the presentation. At the conclusion of the speaker’s talk, persons indicating they had a question would be recognized one by one. Their smartphone (via the TEDMED Connect app) would become a microphone so that their question could be broadcast over the speakers in the auditorium and the video feed. They would stand up, ask their question into the microphone of their smartphone and engage with the speaker, then sit down and let the next person participate. Time is always an issue, so this could be limited to 3 people or so.

Regardless of its implementation, TEDMED needs to allow for attendees to engage with the presenters after each talk. Critical analysis is the chief means of raising the discourse at conferences. For TEDMED to cement its place as the preeminent event for discussing the biggest ideas in medicine and health care, its discourse could certainly use a boost.

drchrono Enhances iPad EHR: API, Apps | InformationWeek →

drchrono started with a ‘mobile first strategy’ [1] and now seems to be leading the pack with API access. If I were setting up my own practice, I would be looking veeeerrry closely at drchrono for my EMR [2].

  1. Arguably, if you’re making a digital product, you should always begin by designing for mobile devices first. Not only do most EMR companies not adopt a mobile first strategy, most don’t have any sort of mobile strategy. drchrono has really been a leader here.  ↩

  2. Sadly, I’m doomed to a life of EMRs being chosen for me as I would like for research to be a part of my career, thus I will be relegated to ivory towers of academic medical centers.  ↩

Counterpoint: Why Graduate Medical Education will be fine | Boring EM →

A really great piece by Teresa Chan MD in response to a post on KevinMD entitled, ‘Why graduate medical education is failing,’ by J. Russell Strader MD. I highly suggest reading both.

Dr Chan writes in her conclusion:

This whole Counterpoint has boiled down to one thing: it’s time we got more critical about the blogosphere. We need to stop posting unsupported and non-evidence based conjecture without so much as a shred of corroborating evidence…A blog is not a peer reviewed journal, but it should take the evidence into account when drawing conclusions.

I agree with this sentiment (and think Dr Strader’s post was pretty egregious in its unsupported assertions) but I also think we should be cautious about restricting opinion in any fashion. My fear is that people may hesitate to write a piece or express an opinion because they are afraid evidence exists they may not be familiar with [1]. Blogs and social media function better with the exchange of ideas. When a bad idea is shared, there is an opportunity to do exactly what Dr Chan has done—respond. I have recommended reading both posts because I think both are enlightening representations; I think we’re better off with both posts [2].

  1. This is actually how I feel about resident work hours. I know a large body of evidence exists, but I have not done any research work in that area so I’m not very familiar with it. It would take me some time to find the ‘best’ papers and accurately refer to their conclusions. Thus, I refrain from writing strong opinions about the subject.  ↩

  2. Arguably, Dr Chan’s post would be shorter and more readable if she cut out the vitriol and focused on making a counterpoint.  ↩

Administrative data for HAI surveillance: fuhgeddaboudit! | Controversies in Hospital Infection Prevention →

Good discussion of some of the cons of working with administrative or billing data for research. While sensitivity is quite variable for using stuff like ICD–9 codes to define cases, specificity is generally very high. This can be a good thing so, let’s not throw the baby out with the bathwater. There are instances when these parameters are acceptable.

Most of the research I’ve done has involved administrative data [1]. In the first paper I published [2], I looked at trends in antibiotic use for Staph aureus infections over the past 10 years for hospitalized children. I relied on administrative data which gave me the benefit of using data from children’s hospitals all over the country and allowed me to look at over 60,000 cases going back to 1999. Because ICD–9 coding is not perfect, sure there were cases I missed. But, I can be almost certain (given the generally high specificity) that all 60,000+ cases I looked at were really due to Staph infections [3]. This same study could easily have been conducted at a single institution and would have taken 5 times as long and not had nearly the same power. Or, I could have formed a multi-institution consortium (easily a years worth of work alone) and spent tens of thousands of dollars conducting this same study at multiple sites over multiple years using confirmed microbiology and pharmacology data. (I think I would have come to the same conclusion.)

The conclusion of the blog post by Dr Edmond states:

Perhaps the forthcoming ICD–10 will help, but the fundamental issue of only reviewing physician notes will remain. More sophisticated methods utilizing computerized algorithms for analyzing electronic medical records for case detection will probably be the ultimate solution.

ICD–10 may help, but really the ultimate solution is making the microbiology data (and other laboratory data) more accessible. The Achilles’ heel of using billing data for infectious diseases research is that micro lab data is not contained in administrative datasets [4]. This should improve with wider adoption of EMR systems, as well as natural language processing systems that will allow us to easily parse notes.

Bottom line—many tools exist for clinical research. None is perfect. It’s important to know both the pros and cons of your tools so you can use them appropriately.

  1. Guess what my opinion on administrative data for research purposes is?  ↩

  2. Shameless plug!!! Read my research!! (Don’t really, unless your in peds…and probably only if you’re in peds ID.)  ↩

  3. Admittedly, there is lots of nuance I’m skipping over here. I suggest reading the discussion section of the paper I’ve linked to for some more insight into the limitations of using billing data (and the limitations of that paper specifically).  ↩

  4. What IS in administrative or billing datasets you ask? The general rule of thumb is anything you can be billed for. So, you can see that someone had a blood culture (because they get charged for that) but you don’t have the results from that blood culture. (Depending on the dataset, you may not even know it is a blood culture, only that something was cultured from somewhere on the patient…)  ↩

Finding your role model | American Resident Project →

Role models come in various flavors. Some are experienced, senior professionals who take on trainees as part of their responsibilities. Others are more junior and the relationship feels more like a lateral partnership than vertical mentorship. Role models can even be people in a vastly different field or someone you don’t know personally, but would like to emulate [1]. I think it’s important to not only have a role model, but ideally one from each of these categories. I find they serve different roles and having multiple people you can turn to means you get multiple perspectives. When dealing with a difficult problem, typically no one answer is absolutely right. You have to choose among equally ill-fitting options and having various perspectives to sort through such options helps you get a 360 view.

  1. Hero worship is a real danger with role models you don’t know personally. Remember, nobody is perfect; the sides of others lives we see (especially for well-known people) are carefully curated to give the appearance that everything is effortless and without problems.  ↩

✚ The false epidemic of chronic illness among young, rich Americans

I read a recent article in The Atlantic entitled, ‘Living Sick and Dying Young in Rich America,’ with great interest [1]. In this article, Leah Sottile writes about the chronic illness her young family faces—

I thought this would be the time when we’d be preparing for the rest of our lives: earning money, going on fun vacations, having families, building our careers. And we are, but at the same time, we’re doing it while we’re trying to manage pain symptoms, chase down prescriptions, and secure stable health insurance…

I wondered if this was normal. Do we know so many people who are dealing with pain because people are just getting sicker in general?…It turns out that chronic conditions like what Joe and my friends are dealing with are one of America’s biggest health emergencies.

I read on with incredulity. I have been in medical school 4 years. I have studied and followed public health for the past 9 years. I had no idea America was facing an epidemic of chronic illness among 30-somethings. Why haven’t I heard about this? Why haven’t I been learning about it in my classes or on the wards?

After reading through the source material referenced by The Atlantic, I have a hard time coming to the same conclusions as this article.

The article begins with the author writing about her husband’s struggle with ankylosing spondylitis (an autoimmune disease). Then goes on to talk about a close friend dealing with lupus (another autoimmune disease) and fibromyalgia.

In our close group of friends—who range from 25 to 35 years old—we know people with everything from tumors to chronic pain.

Though this last statement is quite vague, it seems from the initial few paragraphs there is an epidemic of autoimmune disease among young Americans. (The epidemiology of autoimmune diseases is quite dynamic. While the incidence of some have increased, others have decreased.) However, the article only uses the word ‘autoimmune’ four times; instead, the argument is framed in terms of ‘chronic’ diseases (mentioned 10 times).

In support of this epidemic of chronically ill young adults, the article links to a 2013 report by the National Research Council and Institute of Medicine entitled, ‘Shorter Lives, Poorer Health,’ and states—

But it’s not just that Americans are getting sicker—it’s that young Americans are getting sicker…“The panel was struck by the gravity of its findings,” it reads. “For many years, Americans have been dying at younger ages than people in almost all other high income countries.”

Though the quoted sections above are accurate, the conclusion that ‘young Americans are getting sicker’ is not (at least not in terms of chronic diseases). In the summary for the NRC/IOM report, the authors list nine domains where America fares worse than their peer countries:

  1. Adverse birth outcomes
  2. Injuries and homicides
  3. Adolescent pregnancy and sexually transmitted infections
  4. HIV and AIDS
  5. Drug-related mortality
  6. Obesity and diabetes
  7. Heart disease
  8. Chronic lung disease
  9. Disability (noting this specifically amongst older Americans)

In reference to this list, the report notes—

The first half of the above list occurs disproportionately among young Americans. Deaths that occur before age 50 are responsible for about two-thirds of the difference in life expectancy between males in the US and peer countries, and about one-third of the difference for females.

The first half of the list (items 1 - 5) do not encompass any chronic disease [2]. The causes of America’s worse outcomes in these domains are most closely linked to poverty, risky behaviors, and poor access to health care. The report goes on to note that the poor health status of Americans at age 50 is caused by ‘chronic diseases that arise from risk factors (e.g.—smoking, obesity, diabetes) that are often established earlier in life.’ They do not link such poor health status of 50 year-olds in the US to a mysterious explosion of autoimmunce diseases among 20 - 30 year-olds.

The Atlantic article also points to a report from the Univ of Washington’s Institute for Health Metrics and Evaluation entitled, ‘The State of US Health: Innovations, insights, and recommendations from the Global Burden of Disease Study,’ and says—

In fact, a recent report…says that “in some U.S. counties… life expectancies are on par with countries in North Africa and Southeast Asia.”

The report indeed states this, but the report does not support the implied assertion that these lower life expectancies are from an epidemic of autoimmune diseases among young Americans. The IHME writes—

In the US, we found that life expectancy increased, but the number of years Americans spend living with disability also increased. Ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease (COPD), and road injury were responsible for the greatest number of years of life lost in America in 2010. Musculoskeletal, mental, and behavioral disorders, such as low back and neck pain, depression, and anxiety, were the leading causes of years lived with disability. Looking at risk factors for disease and injury, GBD researchers found that dietary risks, such as eating too little fruit, nuts, and seeds and too much salt, were the largest contributors to disease burden, followed by smoking, high body mass index, high blood pressure, high fasting plasma glucose (high blood sugar), insufficient exercise, and alcohol use.

The Atlantic piece also refers to testimony by Steven Woolf MD MPH, director of the Center on Society and Health at Virginia Commonwealth University, in front of the US Senate. They link to a YouTube video from Senator Bernie Sanders as a reference; this video does not contain any of the testimony attributed to Dr Woolf in the article [3]. In fact, during his brief appearance in the video, Dr Woolf mostly discusses the link between poverty and poor health in the US.

Living with a chronic disease—autoimmune or otherwise—at any age is difficult. Doing so at age 30 would undoubtedly be life-changing. I do not wish to minimize any person’s experience dealing with a chronic disease. I do wish for people to accurately understand the nature and distribution of disease so that we can have a meaningful dialog about improving health care. Unfortunately, I believe this article in The Atlantic misrepresents disease in America and detracts from such dialog. Many people worked very hard to produce this research; it is important to honor their work.

The subtitle for this article is, ‘Chronic illness is the new first-world problem.’ Chronic illness has always primarily been a problem in developed countries. In fact, the real news is that chronic illnesses are increasingly a problem in poor counties. The whole world is struggling with chronic illness, not just young, rich Americans.

  1. This article appears in The Atlantic’s ‘Health 2014: Bright spots in a troubled system’ series.  ↩

  2. Arguably, HIV/AIDS (due to advances in anti-retroviral treatment) and drug-related mortality (as outcomes due to chronic mental illness) are now chronic illnesses.  ↩

  3. The YouTube video does contain some testimony from Dr Woolf, starting at the 2:05 mark. However, it doesn’t contain the specific testimony quoted in The Atlantic.  ↩

Transitioning to a New EMR | American Resident Project →

A couple of recent posts [1] have posited that dramatic change will happen as millenial doctors (currently in med school, residency, or junior positions) move up the ranks. This post from Danielle Jones MD is representative of what we are likely to see—astonishment first at the state of current EMRs and incredulity at health care workers resistance to change for improvement. At the very least, millenials may finally resolve medicine and technology’s tenuous relationship.

  1. ‘Can technology be a change agent for health care?’ by Jay Parkinson MD MPH; ‘Change will happen when millennial doctors step into leadership roles’ by Davis Liu MD  ↩

✚ Tech Rounds - Pinboard

[This is the first post in a new series I am launching about the digital tools I use and how I use them. I am always fascinated to read others’ posts about the tools they are using, especially ‘tech people’ who always seem to have the coolest toys. Through this series, I hope to introduce people to tools they may have never seen or novel workflows…at least that’s the idea. Please contact me with any feedback or suggestions for new things to include in Tech Rounds.]

I chose Pinboard as the first subject for Tech Rounds because in less than a couple weeks, it became an indispensable tool for me. Give it a shot and I think you will find it indispensable too.

What is Pinboard—Pinboard is a web-based bookmarking service. Instead of bookmarking a site in your browser, you send it to Pinboard. At the most basic level, it saves a website URL, a title for that URL, a short description, and tags. Though that is the bulk of what Pinboard does, its simplicity belies its power.

Web-based means universal access—The biggest appeal of any web-based service is that so long as you have an internet-connected device with a web browser (a low bar these days), you can access the service. Creating bookmarks in your browser is convenient, but it confines those bookmarks to not just that computer but the specific browser on that computer where the bookmark was created [1]. Also, there isn’t much you can do with browser bookmarks; you can’t save bookmarks from other devices or apps and those bookmarks can’t be sent elsewhere. With Pinboard, you can access your bookmarks from anywhere and do lots of things with your bookmarks.

A universal inbox—I spend many spare moments browsing through content on the internet, usually on my iPhone. Often, I don’t have time at that particular moment to read a 5,000 word New Yorker article, or even a 300 word blog post. Or I come across an interesting service or uniquely designed website that I’d like to take a look at later. I need a single place to stash those things. Previously, I’ve tried using regular bookmarks, Evernote, Instapaper, even a plain text file; each has their own drawbacks [2]. Pinboard’s universal accessibility, simple design, great search, and integration with other apps make it a perfect place to not only stash things temporarily but permanently.

Saving to Pinboard—The simplest way to save a link to Pinboard is to go to the website and add it manually. This also happens to be the most inefficient method. Pinboard supplies a bookmarklet which you can install in any browser’s bookmark bar. Clicking this bookmarklet on any webpage brings up a pop-up that allows you to save the page to Pinboard. This is probably the most common way to save links. I use it often, though I use a slightly different bookmarklet [3]. Many apps have integration with Pinboard, which represents the other way I add bookmarks. My Twitter clients have mechanisms for me to send tweets and links directly to Pinboard. You can also do things like connect your Instapaper account so that when you favorite an article in Instapaper, it automatically send it to Pinboard. IFTTT also supports Pinboard, which increases the uses of Pinboard exponentially.

Using bookmarks—While I use various methods to get bookmarks into Pinboard, I really only use the basic website to access those bookmarks later on. The minimalist design of the website make easy to use and the search functionality with tag cloud make finding anything a breeze. The only other places I access Pinboard is through ReadKit (a Mac app I will cover in a future post) and my iPhone [4]. Pinboard is also my default ‘read later’ service.

Never delete—With regular bookmarks, Instapaper, and Evernote, I feel compelled to keep things neat and organized. I give Pinboard no such regard. I have a low threshold for saving something to Pinboard and almost never delete anything. Pinboard’s search makes such a cavalier attitude acceptable. Search is quick and comprehensive; I have yet to have a problem finding something [5].

Hopefully this has given some insight into how I’m using Pinboard to make my life a little easier. This is only a primer; there are many, many more features and uses for Pinboard (I didn’t even mention the social features…probably because I don’t use them). For a little bit more on Pinboard and some other tips on how to use it, check out ‘A Beginner’s Guide to Pinboard’ on Shawn Blanc’s blog. Please let me know if you have any questions or comments.

[I have no relationship with Pinboard, financial or otherwise. I would not promote something on mediio if I had such a relationship.]

  1. Yes, it is very much true that synchronization in Chrome and Safari has changed this to a degree but those services have not made the bookmarks universally accessible.  ↩

  2. Regular bookmarks aren’t easily or universally accessible and aren’t searchable. Evernote will work as a universal inbox, it just seems ill-suited to the task. Instapaper was my go-to universal inbox before I switched to Pinboard. But, like Evernote, it really isn’t designed for bookmarking stuff temporarily. Plain text files for bookmarking…I don’t think I even need to discuss why that is a horrible idea.  ↩

  3. Per Shawn Blanc’s suggestion, I’m using Joel Carranza’s “Particular Pinboard” bookmarklet. Installing this bookmarklet is a little tricky because it’s only hosted on github. Here is the easiest way to do it for most people: Install the default Pinboard bookmarklet following their instructions. Once you have done this, go to this website and copy all the jumbled text on it (don’t worry, this is just the raw javascript from Joel’s bookmarklet). Now go to the original Pinboard bookmarklet in your bookmarks bar and right-click to edit. Paste the copied code into the ‘address’ or ‘URL’ field (which should already contain some jumble that starts with ‘javascript’). Then save this.  ↩

  4. Several Pinboard apps exist for smartphones and tablets. I’m currently using Pinner on my iPhone, but am still open to suggestions.  ↩

  5. Recently, I wanted to reference all the 23andMe stuff that went down a few weeks ago for a post. Instead of searching Google or my own blog, all I had to do was search ‘23andMe’ in Pinboard to find virtually everything I had read myself on the subject.  ↩

Medical trainees have access to far too many resources | Sharon Rikin MD →

But often we are too far removed from the actual money exchanging hands to see the necessity in practicing cost-effective medicine.

In addition to being removed from the impact of care costs, we are far too removed from the other 'costs' of tests—time, pain, and sequelae (i.e.—additional testing, scarring, stress, etc). For most of us, it is a simple checkbox on a screen. I think we need to be periodically reminded of all costs, not just financial ones. And I agree with Dr Rikin, we constantly need to ask ourselves, 'What is the one best test?'

Twitter buzz about papers does not mean citations later | Nature →

The title of this article should be updated to include ‘…for now’. Despite the number of active participants we see in our own online circles, the use of Twitter among academics is still relatively novel. Among my professional colleagues [1], I would estimate less than %10 actively participate online and even less than that use it as a professional tool [2]. Among my medical school classmates, use is muuuucch higher, but again, students are largely not using it as a professional tool and certainly not using it to keep up-to-date on the latest research. In the near future, this will change—more and more academics will become active on social networks and a greater percentage of their use will be for professional purposes.

  1. That is, more senior colleagues that I research with and those working as attendings.  ↩

  2. As opposed to using social media to keep up with friends and family or interacting with other for purely recreational purposes.  ↩

Doctors and Secondhand Stress | 33 charts →

An excellent post from Doctor V. I truly think this begins with scheduling. I have worked with physicians who regularly overbook their schedule; their care suffers. They don't think it does; they tell themselves that they are doing a service to their patients by squeezing an urgent appointment in, but neither is true. Good medicine takes time. Avoiding passing on secondhand stress is partially about mindfulness and focus when you walk in the exam room door, but this is certainly better accomplished when you aren't thinking about the 5 other patients already waiting.

Finally, Digital Health Startups Get The Same Toys As Everyone Else | Omada Health →

This is an older link, but I missed this news originally and think it is vitally important to anyone interested in medicine and technology. In the past, many tech companies that provide useful tools for startups (like Amazon Web Services) were not taking the necessary steps to become HIPAA-compliant (in terms of signing contracts; their services have been plenty secure for some time). Changes to HIPAA within the HITECH Act—which took effect in Sept 2013—meant these companies would have to start complying. Thus, many new tech tools are now available to digital health startups.